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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. CI(I Job Address 874 EAST WOODWARD AVENUE City 1�iANTECA Lot Size PM Owner's Name BUDGE BROWN Address SA1,1E Phon�,2 0 9) 2 3 9-9 5 6 6 ..1 OAKWOOD LAKE CONSTRUCTION SAME Contractor's Name License Na.' Phone S TYPE OF WELL/PUMP: NEW WELL,C1 WELL REPLACEMENT-❑w -. DESTRUCT4ON-C - PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ff DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES- DISPOSAL FLD. PROP:-LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _-Approx. Depth ElEastern Surface Seal Installed by J . Repair Work Done '❑ Type of Pump H.P. State Work Done Well DestrgctioA ❑ Well Diameter _. _- _ _- - Sealing-Material,(top 501 Depth Filler Material (Below 501 TYPE.OF SEPTIC WORK: NEW INSTALLATION Z REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200.fee t r Installation will serve: Residence_ Commercial_ Other Number of living unite: Number of bedrooms "2: O Character of soil to a depth of 3 feet: SANDY Water table depth C C SEPTIC TANK r �S Type/Mfg P R_ W&AW T Capacity ,9—l''No. Compartments. - 1 PKG. TREATMENT PLT. ❑ Method of Disposal .@C ] rig ` Distance to nearest: Well Foundation Property Line LEACHING LINE � No. & Length of lines Total length/size �Q FILTER BEDS " ❑ Distance tq n�ease Foundation Property Line SEEPAGE-PITS '❑ 'Depth" Sizeti' / Number R SUMPS. ❑ Distance to nearest:. Well e,`fFoundation Property Line DISPOFAL PONDS ❑ r hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. •� Homb owner or licensed agent's signature certifies the following: "I certify,that in the performance of the Work for which this permit is issued, I shall.not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature- certifies the follow' g: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- - tion laws of Calif. ia." The applicant t call or al uired ins ctions. Complete drawing 12;q4��Signed Title: Date: FOR DEPARTMENT USE ONLY Er Application Accepted by � Date Area , Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 --O Manteca-8237To4 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT"N0, + EH 13.24{REV.10/831 �r / S [� 1 I�-'� �' _829 EH 14-28